Wednesday, May 25, 2011

Hi everyone! On Monday I talked about how The Writer's Guide to Psychology is useful and generally fabulous. Today, the author, Dr. Carolyn Kaufman, is here to tell you about cutting edge treatments for depression.

I don't know if you folks know this, but Dr. Kaufman is an assistant professor at Columbus State Community College and also teaches classes at Otterbein College. She'll stop by later to answer any questions you have, but as a result of her teaching schedule, it will probably be in the afternoon and evening.

In addition, she's giving away one signed copy of The Writer's Guide to Psychology to one of my commenters today! I'll be announcing the winner Friday. And without further ado ...

If your character has a serious problem with depression, you probably think she has two options for treatment: psychotherapy or medications.And you’d be right – sort of.Those are the first two things a good therapist will try. But what happens if neither approach works?Are there cool new 21st-century alternatives?

You bet there are.

Now, in most cases, your character will start with psychotherapy, and in many cases, psychotherapy alone is sufficient.Sometimes, however, medications warrant serious consideration; here are a couple of examples of situations when your therapist will want to consider referring to a psychiatrist:

The client is so depressed that she’s unable to really get much out of therapy – she needs additional help.

The client has numerous close family members who are taking medication for the same condition – and they’re benefitting from that medication or medications.

Once in a while, however, an individual has what we call Treatment-Resistant Depression (TRD), which means that various psychotherapeutic approaches and medications have been inadequate to help the person.Research suggests that for these people, Treatment as Usual (TAU) may only be successful in about 7% of cases.

The Old Standard

Traditionally, electroconvulsive therapy (ECT) has been used as a last-ditch effort in these situations.The good news is that ECT is not the brutal, barbaric thing portrayed in most movies, where the wide-awake patient is strapped down and subjected to painful, terrifying shocks that cause convulsions.Rather, the person is both asleep (thanks to a general anesthesia) and still (thanks to a muscle relaxant). Miraculously, some people feel significantly better after a single treatment, but for most people, several weeks’ worth of treatments are necessary. After that, medications and psychotherapy are usually effective.

The biggest downside of ECT is that it interferes with what we call the “consolidation” of memory.In other words, over the few weeks that you’re doing ECT, you may have trouble storing information in long-term memory. That can certainly make it hard to remember your next appointment if you don’t have it written down!

Though most people say they would do ECT again if they needed it, and though it has been called “no more unpleasant” than going to the dentist (?!), some people have really bad experiences with it. For example, once in a while people who have undergone ECT say that they have problems with anterograde memory loss (which means they have trouble remembering things even after the ECT is done). Others say they have retrograde amnesia, which means they have forgotten chunks of their past.The hard thing about these situations is that normally ECT is only done when the doctors don’t know what else to do to keep someone alive.So which is worse – being dead, or having some memory loss?The answer genuinely depends on the person.

But scientists have been working on new, drug-free biological treatments for people with TRD.Here are three.

Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation is the least invasive of the three new treatments I want to discuss.Unlike the other two, there is no surgery and no implantation of a device.

During TMS, the client sits in a chair that resembles a dentist’s chair (I know, what’s with the recurring dentist theme?), and an electromagnetic coil is placed near the left front of the head. The coil turns on and off rapidly, creating a magnetic field that stimulates the brain’s cells (called “neurons”) to release brain chemicals like serotonin and norepinephrine. (In people who are depressed, serotonin and norepinephrine levels are too low.)

The machine makes a very loud (and unpleasant) tap-tap-tap-tap sound as the electromagnetic coil is turned on and off, so both client and doctor wear earplugs. Many people experience prickling or discomfort of the scalp under the coil, and some experience twitching of facial muscles or headaches afterward. Research suggests, however, that about half of the people who undergo TMS experience some relief of their depression symptoms.

Vagus Nerve Stimulation (VNS)

Both Vagus Nerve Stimulation and the next treatment we talk about, Deep Brain Stimulation, involve a bigger commitment than TMS.Both involve the surgical implantation of an expensive pacemaker-like device under the collarbone.

With VNS, wires run from the main device up into the neckand are wrapped around the vagus nerve, which travels up into the brain and down into the body. Every five minutes, the VNS unit emits a mild electrical pulse.At first, this pulse is noticeable: it feels like a very mild shock accompanied by the requisite prickle of electricity on the left side of the voice box.Over time, however, the body adjusts and the individual is no longer aware of the pulses unless she’s paying close attention, exercising heavily, or speaking loudly (the pulse makes some people’s voices a little bit husky or hoarse). The prickling sensation goes away, and the pulse itself feels like a finger laid very lightly against the left side of the voice box.

The effects of VNS take time, and patients may take up to a year to get the full effects.The battery in the unit is said to last up to 7 years in some patients; when it runs out, a whole new pacemaker-like device has to be implanted.

Research argues that significantly more people with TRD respond to VNS therapy than treatment as usual (ie therapy and medication alone), with about a third of patients getting significant relief and up to 80% of patients getting some relief.

Deep Brain Stimulation (DBS)

Still in the experimental stages, Deep Brain Stimulation also involves the implantation of a pacemaker-like device under the collarbone.Rather than wrapping around the vagus nerve, however, the electrodes are placed directly into the brain.Patients are awake when the electrode is actually inserted, and many, fascinatingly, report an immediate lifting of their depression.Early research has shown that patients have remained in remission while the current is left on, but experience a return of symptoms when the current is switched off.

What makes DBS unique is that it may help people for whom electroconvulsive therapy has not been effective.TMS and VNS are not usually helpful for this group.

Since DBS has not been proven in large groups of people, it has not yet been approved for depression in North America.

Particularly with the last two treatments, you may think that you wouldn’t want someone implanting anything in your body – and especially in your brain – for any reason! But for people for whom depression is an unrelenting specter, these treatments offer new hope.Unfortunately, although both TMS and VNShave been FDA-approved for depression in the US, insurance companies aren’t usually willing to pay for them, forcing individuals to find ways to pay for them out of pocket.

What do you think? Had you heard of these treatments? What questions do you have for Dr. Kaufman (they don't have to be limited to these treatments--feel free to ask general questions or anything about The Writer's Guide)? Remember--one commenter will win a signed copy of The Writer's Guide to Psychology, so ask (or just comment) away! She'll stop by after 3pm (EST) to answer!

32 comments:

Interesting! I had no idea that ECT was still in use, and I've never heard of the other procedures. Implanted devices that administer electric pulses sounds like something right out of a science fiction novel!

Okay, wait ... depression can get so severe that you need THESE types of treatments? What kind of symptoms do people have that require this? And how long do the symptoms have to go on before they realize it's TRD?

Oh wow. I had no idea ECT still existed and was used effectively. My psych 101 professor seemed to dismiss it pretty much out of hand.

The last two are really interesting, and I'd never heard of them. I think it's important for people to remember how debilitating depression can be, and how desperate people become. In a way, it's a as life threatening as anything else treated with a pacemaker

i know a gal who had the vns implant thing. she says she feels like she's being choked every single time that thing goes off. it's really increased her levels of anxiety. but then she had it implanted primarily as an attempt to control her seizures and hopefully to help her depression as well... maybe the settings and such are different in vns for seizures?

I guess the history buff in me wonders how anyone came up with the idea of ECT in the first place. And what level of current is used? The "convulsive" part makes it sound (as you say is often depicted in the movies) as if the patient is writhing about.

It's good to hear there are other treatments, but my heart sank at the dreaded "insurance won't pay..." My heart goes out to the sufferers of such debilitating depresssion.

Amazing stuff. I've read about ECT, but not the others. They do seem scary to me. Do they frighten severely depressed patients, or do those patients welcome them, I wonder.

Also, a writer question for Dr. Kaufman: how would an intractably depressed character react to a physically threatening situation? (Let's make it not life-and-death, but threat of serious physical violence.) Would their reaction be consistent with their essential personality, or would the depression actually reform their personality to an extent that they would react differently?

hi miss sarah and miss carolyn! wow! that was just real cool stuff for helping out with being depressed. im thinking someone that could feel theres no hope could be soooo happy for that new stuff & wanna try it. for sure all this info could be a big help for writers. i got a question and its does those new ways of helping depression got side effects like pills do? it could be real neat if they dont. ...hugs from lenny oh...my commenters not working so its just sayng im an anon :(

wow- thank you so much for all of this information carolyn. I especially find the DBS implant really fascinating- like an 'off' switch for depression. I have a hard time grasping some of the causes for that kind of depression though.

Wow! All of those options are news to me! Very interesting. My question is whether these newer techniques have the same potential side-effects as anti-depressants? And whether they'd be used in conjunction with meds or separately.

Several people asked about how extreme the depression has to be:Depression can last so long and other treatments may not be effective, so in those situations, these treatments are alternatives. Typically the person has to have pretty severe depression (ie major depressive disorder – Behavenet Capsules has the criteria for a major depressive episode at: http://www.behavenet.com/capsules/disorders/mjrdepep.htm) or bipolar I or II disorder (http://www.behavenet.com/capsules/disorders/bip1dis.htm) , though.How long does it have to last? Well, you want to be pretty sure it’s TRD before you go to extremes (especially with the implants), and I’ve seen definitions, but I can’t seem to find them now. Theoretically you would have gone through quite a bit of therapy and many if not all of the categories of antidepressants, for example. In some people who don’t respond to the most common type of antidepressant (SSRIs like Prozac or Effexor), MAOIs are actually helpful. (You have to be more careful with MAOIs because they don’t mix well with a lot of common foods and drinks, but they do help a lot of people with TRD.) A really good psychiatrist also knows how to do things like augment antidepressants with thyroid medications, or may try some off-label meds before they get to things like VNS. The people who get implants like VNS have often struggled with depression for years, if not decades, and sometimes for their whole lives. They’re willing to try just about anything to live a normal life.

Matthew MacNish – Aww, thanks!Also – the “android” (whose head is partially open so you can see her brain – eek!) is demonstrating where the person would sit. I took the pictures of the TMS machine at last year’s American Psychological Association Conference, where they were demonstrating how TMS works so interested people could see.

Vicki – Thanks, I think you made me blush! ;)

Aspiring X – VNS started as a treatment for epilepsy, but people who also had depression were noticing it was helping them. It’s used in a really different way for epilepsy, though – you only turn it on when you feel a seizure coming on, so you probably wouldn’t get used to the pulses the same way you do with depression, when it’s going off every 5 minutes.

The way someone came up with the idea of ECT was they noticed that people w/ epilepsy never had schizophrenia. (Which is not true, sometimes the two conditions exist together, but it’s not real common.) So they thought – Huh, since an epileptic seizure is an abnormal burst of electricity in the brain, let’s try causing that to see if we can cure schizophrenia that way! (Kinda scary the way these early shrinks thought sometimes.)ECT started out as a coma state induced through an overdose of insulin; later they switched to electricity. It started out as an awful treatment, with convulsions and all that; in the US, all ECT is now the “modified” kind I described, though. There’s a lot of information about ECT – including how strong the stimulus is, how long the seizure lasts, and so on, in the Writer’s Guide to Psychology if you want all the detailed details. (I got someone who performs ECT to talk with me, which was a feat, and she also lent me some of her manuals on how it’s done, so I got a lot of really great info for the book.)

Linda Gray –

No, these are really not frightening things (though I’m sure most people who approach ECT for the first time are somewhat scared, just like anyone who’s approaching a procedure under general anesthesia) as much as they are possibilities when others have failed. So they can actually be exciting.

With regards to your question, their reaction should be consistent with their personality – probably a strong version of their personality – rather than something affected by the depression. If it were life and death and your character were extremely suicidal, that might change things, but since it’s not…

Lenny—Nope, these don’t have the same kinds of side effects that medications do, and that’s one of the benefits. However, they do have their own side effects, some of which I think I mentioned in the post. For example, TMS can leave people with a headache (and so can ECT, though that may be from the general anesthesia). VNS can make the person’s voice husky, and so on.

Lisa Gail Green –

A lot of people who get TMS, VNS, and DBS are hopeful that they will no longer need meds, and the research suggests that some people do go into full remission, but many others do still need to take medications, though perhaps not as much. Following ECT, meds are always used to help maintain the improvements.

hi miss carolyn! im thinking one of my brothers is one of those trds cause nothing worked on him. then he got on a moi and its called nardil & its been working for a long time. now hes not careful bout what he eats and didnt have any problem but hes still just real careful bout other medicines. is eating what you want ok after you do that moi for a long time? ...from lenny

Well, maybe your brother has learned what he can and can't combine with his Nardil. :) You only have to be careful about some specific types of processed foods. Others you just have to limit. For those who are interested, there's an exhaustive list here: http://www.upmc.com/HealthAtoZ/patienteducation/Documents/MaoiDiet.pdf

No, Lydia, those things don't happen, though some people find heavy exercise to be more difficult. I think I forgot to mention that the stimulation can be turned off with a strong magnet held over the device. That VNSandME Wordpress blog (listed above) is really interesting if you want to see a firsthand account.

Wow. I'm always amazed by the stuff I don't know. And being honest, I didn't retain all of this on a first read; I did read through twice. I'll probably be back to read it again. So interesting! I think I've mentioned before, every time I visit I end up taking notes! Thanks for the information.

About Me

I'm a child psychologist with an unapologetically empirical orientation. I'm also an author who writes unapologetically fantastical YA fiction. In that venture, I am repped by Kathleen Ortiz of New Leaf Literary and Media. SANCTUM and FRACTURED, the first two books in my YA urban fantasy series, GUARDS OF THE SHADOWLANDS, are available now (Skyscape/Amazon Children's Publishing). Book 3 in the series comes out 10/14. My co-authored (with Walter Jury) YA thriller, SCAN, comes out in 5/1/14 (Putnam & Sons/Penguin). OF METAL AND WISHES, my gothic YA, comes out in 8/5/14 (McElderry/Simon & Schuster). I also write adult paranormal romance for 47 North/Amazon. I like to stay busy.